By Victoria Stern

A new single-port pretumoral approach has shown promise in treating early breast cancer, according to a new study presented at the 21st International Congress of the European Association for Endoscopic Surgery (EAES).

This pretumoral transaxillary retromammary (TARM) approach to video-assisted breast surgery (VABS) performed on 20 patients was safe and effective. The approach also came with excellent cosmetic outcomes, preserving the original shape of the breast, said lead author Koji Yamashita, MD, PhD, Department of Breast Surgery, Nippon Medical School, Tokyo. He presented the results at the EAES meeting in Vienna, in June.

Currently in the United States, the standard of care for breast-conserving surgery includes lumpectomy, partial mastectomy and quadrantectomy, but these methods require a long incision above the tumor and can significantly scar or deform the breast.

Endoscopic breast surgery, developed in Japan in 1995 to reduce the number of incisions and improve cosmesis, has continued to gain popularity in Asian countries.

Several endoscopic procedures have emerged, including endoscopic nipple-sparing mastectomy (Ann Surg Oncol 2009;16:3406-3413) and approaches that involve a periareolar incision, an axillar incision or both. VABS, for instance, requires two small incisions that can be hidden along the axilla and at the edge of the areola, and TARM-VABS is less invasive, requiring only one incision in the axilla, which avoids wounding the breast skin altogether.

“Aesthetics is an important factor, and studies show endoscopic approaches are both oncologically safe and show better cosmetic results,” said Eisuke Fukuma, MD, PhD, director of Breast Center, Kameda Medical Center, Kamogawa City, Japan, who was not involved in the current research.

In 2008, Dr. Yamashita reported the initial success of the TARM-VABS technique on 12 patients (Chin Med J [Engl] 2008;121:1960-1964), and 20 patients (Am J Surg 2008;196:578-581), and, two years later, on 120 patients with early stage I and II breast cancer (Cancer Res 2010;70:P4-10-08). In all three studies, Dr. Yamashita and his colleague Kazuo Shimizu, MD, FACS, reported that although the TARM-VABS approach took 45 minutes longer than conventional VAB, all TARM-VABS patients showed negative surgical margins and better cosmetic outcomes.

The TARM-VABS approach is technically feasible, but can be difficult to learn and perform, which is why Dr. Yamashita recently developed a pretumoral TARM-VABS approach to simplify the technique.

“In TARM-VABS, the cutting manipulation is difficult from the backside of the mammary gland through the single axillary port.” The pretumoral approach is easier to perform because it requires later dissection behind the mammary gland, said Dr. Yamashita.

In the current study, Dr. Yamashita and his colleagues performed the pretumoral TARM-VABS approach on 20 patients with early-stage breast cancer, who were aged 50.2 years, on average, and had a mean tumor size of 2.2 cm. After endoscopic sentinel lymph node biopsy, Dr. Yamashita’s team made a 2.5-cm axillary skin incision and marked the cut margins with blue dye. The surgeons dissected the subcutaneous tissue above the tumor and cut the mammary gland with clear surgical margins, removing the tumor through the axillary port using EndoCatch (Covidien). After tumor removal, they reconstructed the breast, filling the tumorless area with absorbable fiber cotton or mesh. Average follow-up time was 48 months.

With the pretumoral TARM-VABS approach, all patients had negative surgical margins and no serious complications after surgery. Minor complications included small subcutaneous hemorrhage and temporary mild inflammation around the resected area of the breast. Average operative time was 127 minutes and resected volume was 24.5%. Patients also experienced high levels of satisfaction six months after the operation, rating their aesthetic outcomes an average of 13.8 of 15 total points.

Despite the promising results, endoscopic breast surgery is not yet standard of care in clinical practice.

“To allow this approach to become a standard of care, I have to improve the manipulating devices to perform this operation more easily and introduce this surgery to more surgeons and patients,” Dr. Yamashita said. He also is planning to perform a prospective study comparing the TARM-VABS approach with conventional breast-conserving surgery.

Dr. Fukuma believes that a nonsurgical approach for treating small breast cancers called cryoablation may be the future of care. Cryoablation for breast cancer involves freezing and killing small tumors (≤1 cm), using ultrasound guidance and local anesthesia. Since 2006, Dr. Fukuma and colleagues have used cryoablation to treat 58 patients with breast cancer (2013 American Society of Breast Surgeons annual meeting; abstract 0106). The procedure is safe, and no local tumor recurrence or distant metastases have occurred.

“We hope to expand this approach for larger breast tumors,” said Dr. Fukuma. “But currently endoscopic surgeries represent good options and we must continue to educate doctors in these methods.”

Drs. Fukuma and Yamashita reported no relevant conflicts of interest.